Navigating a long term disability appeal can be tough. The long term disability appeal process is marked by a set of challenges that go beyond dealing with a disabling condition. Your insurance company will scrutinize your appeal submission for any justification to deny your benefits, and without strong, comprehensive evidence rebutting their initial adverse determination, you may receive a second denial – one that can only be overturned via a lengthy, expensive litigation.
In this article, we’ll discuss the red flags that indicate your insurance company may deny your appeal, common mistakes made by claimants during the appeals process, and what you can do to maximize your chances of a successful outcome.
What Are the Red Flags That My Insurance Company Will Deny My Appeal?
The disability insurance appeals process can be a minefield. Understanding potential red flags that may indicate a denial is crucial for navigating the appeals process effectively. In this section, we’ll explore key warning signs to help you recognize and address potential hurdles that could arise during your appeal. While each of these red flags is not a death knell to your appeal, each of them is something to watch out for and fix, if possible. The best fix for each of these red flags is appropriate testing and the opinion of your doctor that you meet the definition of disability in your long term disability policy.
1. Your insurance company requests an Independent Medical Examination (“IME”)
The demand for an Independent Medical Examination (“IME”) by your insurance company can be a concerning red flag that they may deny your appeal. An IME request implies a lack of trust in the evidence you’ve submitted, suggesting that your insurance company is casting doubt on the legitimacy of your disability. Your insurance company may use the IME as an opportunity to obtain an opinion favoring denial from an examiner they’ve selected and compensated. This not only adds an additional layer of stress for you as the claimant, but it also raises questions about your insurance company’s commitment to a fair and impartial evaluation of your case, potentially creating an uphill battle in your pursuit of deserved benefits.
What You Can Do: To mitigate the impact of an IME on your appeal decision, you can take several proactive steps. Firstly, thorough preparation is key— provide the examining physician with comprehensive information about your medical condition, symptoms, and daily limitations. You may also enlist a witness, whether it be a professional nurse service or a family member or friend, who can attend the IME with you. Afterward, have your witness provide a detailed account of what transpired during the examination, including the length of the exam, what questions the examiner asked you, and any special tests or tools the examiner used during the exam.
Make sure to request a copy of the IME report from your insurance company immediately. It is crucial to obtain detailed rebuttals from your treating physicians to counter any potentially biased or unfavorable opinions expressed in the IME report. These rebuttals should clearly articulate the medical basis for your disability and address any discrepancies between the IME findings and your existing medical records. This strategic approach can strengthen your case, providing a more comprehensive and accurate representation of your disability during the appeal process.
2. Your insurance company has an in-house medical consultant review your paper file.
It can raise a red flag if your insurance company enlists an in-house medical consultant to review your paper file. This action implies a level of skepticism towards your submitted medical documentation, as your insurance company seeks an internal expert’s opinion to assess the legitimacy of your disabling condition. In-house consultants may also have a financial interest in supporting your insurance company’s position, potentially influencing the outcome. The use of a medical paper reviewer prompts legitimate concerns about your insurance company’s commitment to an impartial and fair evaluation of your appeal.
What You Can Do: To “rescue” your appeal in this situation, you should take proactive measures. First, request copies of the paper reviewer’s opinion to understand the basis of their assessment. Confirm what evidence your insurance company provided the paper reviewer before writing the report; if any of your submitted medical documentation is missing from that list, argue that the medical consultant’s opinion is incomplete and therefore unreliable.
Make sure to obtain detailed rebuttals from your treating physicians. These rebuttal letters should emphasize the importance of an in-person, long-term treating relationship that a mere paper review cannot capture. Additionally, your doctors should address any inaccuracies or inconsistencies in the paper reviewer’s opinion, providing a strong foundation for your appeal.
3. Your insurance company’s doctor says you are not disabled even after your provider submits a rebuttal to their report.
The persistence of your insurance company’s medical consultants and/or examiners in maintaining the opinion that you are not disabled, even after your healthcare provider submits a rebuttal, is a significant red flag. Your insurance company’s apparent reluctance to consider the perspective of your treating providers, who have a deeper understanding of your medical history, suggests a potential bias in favor of their own consultants and examiners.
What You Can Do: If your insurance company’s medical consultants and/or examiners persist in their opinion that you are not disabled despite your provider’s rebuttal, there are strategic steps you can take to bolster your appeal. First and foremost, seek additional rebuttals from your treating providers, especially specialists who can provide in-depth insights into the specific nature of your disabling condition. Additionally, if the paper reviewer or examiner lacks specialization relevant to your condition — for instance, a neurological condition being assessed by a psychiatrist — highlight this to your insurance company. Clearly articulate the importance of having an expert with the appropriate specialization to ensure a thorough and accurate evaluation of your appeal. This approach aims to address potential biases and strengthen your position in the appeal process.
4. Your insurance company conducts surveillance on you.
If your insurance company conducts surveillance on you during the appeals process, it is likely a red flag that they are seeking justification to deny your claim for benefits. In addition to in-person surveillance, disability insurance companies also regularly engage in social media surveillance. Surveillance suggests a lack of trust in the restrictions and limitations you’ve reported due to your disabling condition. Your insurance company may be hoping to catch instances where you may be perceived as exceeding the claimed functional limitations.
What You Can Do: If you discover that your insurance company is conducting surveillance during your appeals process, it’s crucial to address this situation before they make a decision. Request the full footage to ensure a comprehensive understanding of the context. Insurance companies may present selectively edited portions as evidence, potentially misrepresenting your capabilities.
Additionally, share the footage with your treating physicians and ask them to provide written statements assessing whether the observed activities align with your reported symptoms and restrictions. These statements can be valuable evidence to counter any misinterpretation of surveillance footage during the appeal process. By taking these proactive measures, you can better protect your rights, present a more accurate picture of your disability, and strengthen your position in the face of potential challenges posed by surveillance evidence.
5. Your insurance company tries to delay making a decision on your appeal.
Engaging in deliberate delay tactics, such as repeated and unreasonable requests for additional information without clear justification or scheduling unnecessary evaluations, can be a red flag that your insurance company is seeking to deny your appeal. This tactic raises concerns about your insurance company’s commitment to a timely and fair resolution. Your insurance company may be using procedural maneuvers to avoid a prompt and thorough evaluation of the appeal. Of course, delays can also cause you prolonged financial strain and uncertainty.
What Can You Do: If your insurance company attempts to delay making a decision on your appeal, there are ways to fight back. First, keep meticulous records of all communications with your insurance company, including dates, times, and details of conversations. This documentation can serve as evidence of any unwarranted delays. Make sure to politely but firmly inquire about the status of your appeal. Regularly follow up with your insurance company to express the importance of a timely resolution.
Under the Employee Retirement Income Security Act (“ERISA”), insurance companies are typically bound by specific timelines for responding to appeals, and knowing these can empower you to advocate for your rights. If you are facing unnecessary delays in your appeal decision, consult with an ERISA attorney. An attorney experienced in disability insurance appeals can navigate the legal complexities, advocate on your behalf, and ensure that the insurance company adheres to established timelines.
By taking these proactive measures, you can mitigate the impact of unjustified delays, protect your rights, and work towards a fair and timely resolution of your appeal.
What common mistakes do claimants make when filing an appeal?
It’s all too easy for claimants to find themselves navigating a complex and unfamiliar landscape when dealing with an appeal. The emotional and financial toll of a denied claim adds an additional layer of challenge, making it understandable that mistakes may arise during the appeals process. Below we’ll discuss common mistakes claimants make when filing an appeal and how to avoid them.
Under the Employee Retirement Income Security Act (“ERISA”), if your claim for disability benefits has been denied, you typically have 180 days to submit an appeal to the insurance company. This period is known as the “administrative appeal” or “internal appeal” period. It’s crucial to adhere to this deadline, as failure to file the appeal within the specified timeframe may result in the loss of your right to challenge the denial.
Keep in mind that the specifics of the appeals process, including timeframes, may vary depending on the terms outlined in your particular insurance policy or plan. Therefore, it’s essential to carefully review the denial letter from your insurance company, as it should provide information about the deadline for submitting your appeal and any specific requirements or procedures you need to follow. If you have questions or concerns, consulting with an attorney experienced in ERISA matters can provide valuable guidance.
What You Can Do: If you miss the appeal deadline for a denied disability benefits claim under ERISA, it can significantly impact your ability to challenge the denial. However, there are still potential steps you can take.
First, thoroughly review your insurance plan documents to understand if there are any provisions or exceptions that might allow for an extension or late submission. Some plans may have specific provisions for situations where claimants can show good cause for missing deadlines.
Consult with an experienced long term disability attorney as soon as possible. They can assess your case, review the denial letter, and provide guidance on potential avenues for appeal or legal action. If there are valid reasons for missing the deadline, such as medical incapacitation or misinformation provided by your insurance company, your attorney may help you present a “good cause” argument to the insurance company or potentially in court.
If your insurance company refuses to consider a late appeal or if other options are exhausted, your attorney may advise you on the possibility of pursuing legal action. This could involve filing a lawsuit against your insurance company to challenge the denial.
It’s important to note that missing the appeal deadline poses significant challenges, and success in challenging the denial after such a lapse is not guaranteed. Consulting with an experienced disability attorney early in the process is critical, as they can provide tailored advice based on the specifics of your case and potentially help you explore options for moving forward.
2. You rush to submit your appeal.
Rushing to file an appeal is a common mistake with potentially adverse consequences. It’s understandable why you want to submit your appeal quickly – you may be angry at the initial denial, or you are under financial pressure to get approved for benefits as fast as possible. Unfortunately, by submitting a hasty appeal you risk providing insufficient evidence to support your case.
Insurance companies often uphold denials when the appeal lacks new or compelling information. Without additional evidence, your insurance company will likely reiterate their original decision. A denied appeal can also mean your administrative remedies are exhausted, and your only recourse is litigation. This will only further delay your benefits and add significant expense.
What You Can Do: To avoid the mistake of rushing to file an appeal in a disability insurance claim, claimants should take a methodical and thorough approach. Take the time to collect and organize all relevant medical records, treatment notes, and any additional documentation supporting your disability claim that was not previously submitted to your insurance company. To bolster your medical evidence, seek opinions from healthcare professionals, especially specialists relevant to your disabling condition. Having new expert medical opinions that clearly articulate the severity and impact of your disability can significantly strengthen your appeal.
Engage the services of an experienced long term disability lawyer before submitting your appeal. Legal professionals specializing in disability insurance claims can provide valuable insights into the specific requirements and nuances of the appeals process. They can guide you on how to best present a compelling appeal and maximize your chances of the adverse decision being overturned.
3. You have incomplete or inaccurate documentation.
Having incomplete or inaccurate documentation in your appeal is a significant mistake that can undermine the chances of a successful outcome. Incomplete documentation may leave gaps in the evidence presented during the appeal, hindering your insurance company’s ability to fully grasp the extent of your disability. This lack of clarity can result in a denial or insufficient benefits being awarded during the appeal process.
Inaccurate documentation, whether unintentional errors or inconsistencies, can erode the credibility of the appeal. Your insurance company will likely rely heavily on the accuracy and thoroughness of medical records and supporting documentation when reevaluating your claim. Inaccuracies may raise doubts about the legitimacy of your claim, potentially leading to skepticism and a repeated denial.
What You Can Do: To avoid the mistake of having incomplete or inaccurate documentation in your appeal, carefully review all existing medical records, treatment notes, and any documentation related to your disability claim. Ensure that the information is accurate, up-to-date, and comprehensive in describing the nature and impact of your disabling condition. If your provider’s notes are sparse, request that they provide a supplemental statement opining on your symptoms, restrictions, limitations, and their opinion on your ability to work.
Additional medical testing options, such as a Functional Capacity Evaluation (“FCE”), neuropsychological evaluation, or Cardiopulmonary Exercise Testing (“CPET”), can greatly assist your appeal, depending on the nature of your disability. These tests can provide objective and detailed assessments that strengthen your appeal by offering objective and thorough evidence of your functional limitations.
To make sure your insurance company understands the full scope of your occupation, consider undergoing a vocational assessment. The vocational assessment is an expert evaluation of your skills, education, and work history to provide a holistic view of your employability given the limitations imposed by your disability. The resulting report can be a valuable addition to support your appeal.
Finally, consult with an experienced disability attorney specializing in ERISA cases. An attorney can provide guidance on the specific requirements of the appeal process and help ensure that all necessary documentation is accurate, complete, and aligned with your insurance policy’s criteria.
4. You fail to address the previous reasons for denial.
It’s not uncommon for claimants to fail to address the previous reasons for denial in their appeal, which can be a serious mistake. When you do not thoroughly counter the specific points or concerns outlined in the initial denial, it leaves your insurance company with the impression that the issues raised in the denial letter remain valid.
Addressing the previous reasons for denial is crucial for building a compelling case during the appeal process. Failure to do so may result in your insurance company reiterating their initial decision based on the same grounds, leading to a continued denial of benefits.
What You Can Do: To avoid the mistake of failing to address all previous reasons for denial in your appeal, you should take a systematic and thorough approach. First, carefully review the denial letter provided by your insurance company. Identify and understand the specific reasons cited for the denial of the initial claim. Create a comprehensive list of the concerns raised in the denial letter. This list will serve as a roadmap for addressing each point in your appeal.
You will need to provide new evidence to your insurance company that refutes these reasons for denial. You cannot just resubmit previous evidence, as your insurance company has already determined it is not sufficient. Collect additional documentation and expert opinions that directly counter the reasons for denial. This may involve obtaining updated medical records, conducting additional tests, or securing expert statements from your providers that offer a more comprehensive understanding of your disability.
Systematically address each concern outlined in the denial letter within your appeal. Clearly articulate how the new evidence refutes or mitigates your insurance company’s initial reasons for denial. Make sure to offer context to the additional evidence, explaining how it directly relates to the concerns raised in the denial. Providing a narrative that connects the dots helps in presenting a coherent and persuasive case.
Do not neglect to seek guidance from an experienced long term disability attorney specializing in ERISA cases. An attorney can assist in identifying the critical points to address, ensuring a comprehensive response to your insurance company’s arguments.
5. You fail to consult with an long term disability attorney to help with your appeal.
Many claimants mistakenly believe they can navigate the appeals process alone, only to face a second denial—with their only recourse left being costly litigation. Disability insurance claims, particularly those governed by ERISA, involve complex legal nuances, and claimants may not be fully aware of their rights, the legal requirements, or the potential pitfalls associated with the appeal process. An ERISA attorney with experience in disability insurance appeals can significantly enhance your chances of success in overturning the denial and securing the disability benefits you deserve.
What You Can Do: To avoid this mistake, consult with an experienced disability attorney before filing your appeal. Having legal representation from the beginning can help shape the appeal strategy and maximize your chances of success. However, if you have already filed your appeal on your own, you should still consult with an attorney to determine how they can help. A knowledgeable attorney should be able to provide insights into the strengths and weaknesses of your claim and how they plan to address them.
How can The Maddox Firm help me with my disability claim appeal?
The experienced team at The Maddox Firm has helped hundreds of our clients successfully file an appeal for their short or long term disability insurance benefits. We understand the difficulties in navigating the appeals process, what red flags to look out for, and how to mitigate these issues so you can secure your benefits.
Here are just a few ways we can help you win your short or long term disability claim appeal:
We Examine Your Disability Insurance Policy: The Maddox Firm will conduct a thorough examination of your disability insurance policy to understand its terms, conditions, and any provisions relevant to your claim. This ensures a comprehensive understanding of the basis on which your benefits are denied and helps formulate an effective appeal strategy.
We Handle All Communication with Your Insurance Company: The Maddox Firm will take charge of all communications with your insurance company on your behalf. This includes submitting the appeal, responding to inquiries, and ensuring that all relevant information is properly presented to support your case.
We Identify Any Red Flags from Your Insurance Company: The Maddox Firm can identify potential red flags from your insurance company that may indicate a predisposition to deny your benefits. This proactive approach allows for targeted responses to specific concerns and strengthens your position during the appeal process.
Development of Appeal Strategy: The Maddox Firm will develop a customized appeal strategy based on the specific circumstances of your case. This involves addressing the reasons for denial, gathering additional evidence to bolster your argument for benefits, and presenting a compelling case to your insurance company.
Understanding Necessary New Evidence: Our experienced team will clearly outline the new evidence necessary to support your appeal. This may include obtaining updated medical records, expert opinions from your treating providers, or recommending you for additional testing that strengthens your case and addresses any deficiencies identified in the initial denial.
We Protect Your Rights Under ERISA: The Maddox Firm will advocate for and protect your rights under ERISA throughout the appeal process. We’ll ensure that your insurance company is held accountable for fair and lawful treatment.
We Can Represent You in Court: The Maddox Firm can provide legal representation in litigation if your appeal is unsuccessful and further legal action becomes necessary.
We Maximize Your Benefits: The Maddox Firm will work diligently to maximize the benefits you are entitled to under your disability insurance policy. Our experience in short and long term disability claims allows us to pursue the highest possible benefits for our clients.
If your short or long term disability claim has been denied and you’re looking to appeal, you should always consult with an experienced attorney. The Maddox Firm can help you maximize your chances of a successful appeal of your disability benefits. Our team will examine your insurance policy, correspondence from your insurance company, medical records, and any other relevant documentation in order to give you personalized guidance on how we can help you win your disability claim.